Predicting mortality risk on dialysis and conservative care: development and internal validation of a prediction tool for older patients with advanced chronic kidney disease

Abstract Background Conservative care (CC) may be a valid alternative to dialysis for certain older patients with advanced chronic kidney disease (CKD). A model that predicts patient prognosis on both treatment pathways could be of value in shared decision-making. Therefore, the aim is to develop a prediction tool that predicts the mortality risk for the same patient for both dialysis and CC from the time of treatment decision. Methods CKD Stage 4/5 patients aged ≥70 years, treated at a single centre in the Netherlands, were included between 2004 and 2016. Predictors were collected at treatment decision and selected based on literature and an expert panel. Outcome was 2-year mortality. Basic and extended logistic regression models were developed for both the dialysis and CC groups. These models were internally validated with bootstrapping. Model performance was assessed with discrimination and calibration. Results In total, 366 patients were included, of which 126 chose CC. Pre-selected predictors for the basic model were age, estimated glomerular filtration rate, malignancy and cardiovascular disease. Discrimination was moderate, with optimism-corrected C-statistics ranging from 0.675 to 0.750. Calibration plots showed good calibration. Conclusions A prediction tool that predicts 2-year mortality was developed to provide older advanced CKD patients with individualized prognosis estimates for both dialysis and CC. Future studies are needed to test whether our findings hold in other CKD populations. Following external validation, this prediction tool could be used to compare a patient’s prognosis on both dialysis and CC, and help to inform treatment decision-making.

Download Full-text

Older patients’ experiences with a shared decision-making process on choosing dialysis or conservative care for advanced chronic kidney disease: a survey study

BMC Nephrology ◽

10.1186/s12882-019-1423-x ◽

2019 ◽

Vol 20 (1) ◽

Cited By ~ 2

Author(s):

Wouter R. Verberne ◽

Wanda S. Konijn ◽

Karen Prantl ◽

Janneke Dijkers ◽

Margriet T. Roskam ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Decision Making ◽

Kidney Disease ◽

Shared Decision Making ◽

Older Patients ◽

Survey Study ◽

Decision Making Process ◽

Shared Decision ◽

Advanced Chronic Kidney Disease ◽

Conservative Care

Download Full-text

Pretransplant Comprehensive Geriatric Assessment in Older Patients with Advanced Chronic Kidney Disease

Nephron ◽

10.1159/000517342 ◽

2021 ◽

pp. 1-10

Author(s):

Teddy Novais ◽

Elodie Pongan ◽

Frederic Gervais ◽

Marie-Hélène Coste ◽

Emmanuel Morelon ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Decision Making ◽

Kidney Disease ◽

Activities Of Daily Living ◽

Physical Function ◽

Comprehensive Geriatric Assessment ◽

Daily Living ◽

Older Patients ◽

Advanced Chronic Kidney Disease ◽

Comorbidity Burden

Background: In older patients with advanced chronic kidney disease (CKD), the decision of kidney transplantation (KT) is a challenge for nephrologists. The use of comprehensive geriatric assessment (CGA) is increasingly gaining interest into the process of decision-making about treatment modality choice for CKD. The aim of this study was to assess the prevalence of geriatric impairment and frailty in older dialysis and nondialysis patients with advanced CKD using a pretransplant CGA model and to identify geriatric impairments influencing the geriatricians’ recommendations for KT. Methods: An observational study was conducted with retrospective data from July 2017 to January 2020. Patients aged ≥65 years with advanced CKD, treated or not with dialysis, and referred by the nephrologist were included in the study. The CGA assessed comorbidity burden, cognition, mood, nutritional status, (instrumental) activities of daily living, physical function, frailty, and polypharmacy. Geriatric impairments influencing the geriatricians’ recommendations for KT were identified using univariate and multivariate logistic regressions. Results: 156 patients were included (74.2 ± 3.5 years and 62.2% on dialysis). Geriatric conditions were highly prevalent in both dialysis and nondialysis groups. The rate of geriatric impairments was higher in dialysis patients regarding comorbidity burden, symptoms of depression, physical function, autonomy, and frailty. Geriatrician’s recommendations for KT were as follows: favorable (79.5%) versus not favorable or multidisciplinary discussion needed with nephrologists (20.5%). Dependence for Instrumental Activities of Daily Living (IADL) (odds ratio [OR] = 3.01 and 95% confidence interval [CI] = 1.30–7.31), physical functions (OR = 2.91 and 95% CI = 1.08–7.87), and frailty (OR = 2.66 and 95% CI = 1.07–6.65) were found to be independent geriatric impairments influencing geriatrician’s recommendations for KT. Conclusions: Understanding the burden of geriatric impairment provides an opportunity to direct KT decision-making and to guide interventions to prevent functional decline and preserve quality of life.

Download Full-text

Reanalysis of the physical and mental health summary scores of dialysis versus conservative care in older patients with advanced chronic kidney disease: a critical appraisal

BMC Research Notes ◽

10.1186/s13104-019-4765-3 ◽

2019 ◽

Vol 12 (1) ◽

Cited By ~ 1

Author(s):

Wouter R. Verberne ◽

Janneke Dijkers ◽

Johannes C. Kelder ◽

Wilbert T. Jellema ◽

Johannes J. M. van Delden ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Mental Component Summary ◽

Older Patients ◽

Critical Appraisal ◽

Advanced Chronic Kidney Disease ◽

Conservative Care ◽

Patient Cohort ◽

Sf 36 ◽

Scoring Algorithm

Abstract Objective Non-dialytic conservative care is argued to be a reasonable treatment alternative for dialysis in selected older patients with advanced chronic kidney disease. We evaluated patient-relevant outcomes including health-related quality of life in a previous study. However, the scoring algorithm we used to calculate the physical and mental component summary scores of the Short Form-36 (SF-36) turned out to differ from comparable studies on this topic. The aim of this critical appraisal was to reanalyze the SF-36 summary scores in our patient cohort (≥ 70 years) using the more widely used scoring algorithm. Results Patients on conservative care (n = 23) had lower physical and mental component summary scores compared to patients not yet started on dialysis (n = 39), but similar compared to patients on dialysis (n = 34). These findings were similar to our original findings and did not change the conclusions. Several scoring algorithms are used for the SF-36 summary scores. Researchers should be aware of this fact and should use the same scoring algorithm across similar studies in a specific field to increase comparability. Using the more widely used scoring algorithm, the recalculated SF-36 summary scores of our patient cohort can now be compared to other studies.

Download Full-text

Self-referral of Chinese patients with advanced chronic kidney disease and treatment decision-making: A qualitative study

10.22541/au.160570625.51499988/v1 ◽

2020 ◽

Author(s):

Yajing Gao ◽

Yan Shan ◽

Tingting Jiang ◽

Xue Li ◽

Xinxin Jiang ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Decision Making ◽

Kidney Disease ◽

Negative Emotion ◽

Treatment Decision ◽

Chinese Patients ◽

Structured Interviews ◽

Advanced Chronic Kidney Disease ◽

Treatment Decision Making ◽

Referral Decision

Abstract: Rationale, aims, and objectives: Chinese patients with advanced chronic kidney disease (CKD), especially rural patients possibly occur self-referral behavior and then treatment decisions followed. It is unclear the relationship between self-referral and treatment decision-making. Thus, the aim of this study was to explore the perceptions and views of self-referral and treatment decision making among patients with advanced chronic kidney disease. Methods: We conducted semi-structured interviews with 26 patients with advanced kidney disease and 12 nephrologists. Interviews were conducted and analyzed thematically until reaching thematic saturation. Results: We identified three themes reflected: 1) self-referral decision making (self-referral motive, barrier to self-referral, seeking for self-referral information); 2) the views and experience of self-referral care (facilitating shared decision making, imposing psychological pressure, feeling about self-referral communication, challenge to staff-patient relationship); 3) treatment decision making (decisional awareness and roles, cost-benefit trade-off and redicision). Conclusions: Our study identified that organizational and demographic factors, self-referral motives worked together at the self-referral decision-making and treatment decision-making when advanced CKD patients facing with healthcare facilities and treatment options. Those findings suggest stakeholders should accelerate the popularization of peritoneal dialysis technology and establish the CKD screening and management systems. For self-referral patients with advanced CKD, our results suggest specialized dialysis transition care to improve quality of communication and soothe patients’ negative emotion.

Download Full-text

Self-referral of Chinese patients with advanced chronic kidney disease and treatment decision-making: A qualitative study

10.21203/rs.3.rs-58051/v1 ◽

2020 ◽

Author(s):

Ya jing Gao ◽

Yan Shan ◽

Yue Zhou ◽

Ting ting Jiang ◽

Xue Li ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Decision Making ◽

Kidney Disease ◽

Health Care Professionals ◽

Negative Emotion ◽

Treatment Decision ◽

Chinese Patients ◽

Advanced Chronic Kidney Disease ◽

Treatment Decision Making ◽

Referral Decision

Abstract Background: Chinese patients with advanced chronic kidney disease, especially rural patients possibly occur self-referral behavior and then treatment decisions followed. It is unclear the relationship between self-referral and treatment decision-making. Thus, the aim of this study was to explore HCPs and patient with advanced CKD perceptions of self-referral and treatment decision making. Methods: We conducted semi-structured interviews with 22 patients with advanced kidney disease and 8 health care professionals. Interviews were conducted and analyzed thematically until reaching thematic saturation. Results: We identified three themes reflected: 1) self-referral decision making (self-referral motive, barrier to self-referral, seeking for self-referral information); 2) the views and experience of self-referral care (facilitating shared decision making, imposing psychological pressure, feeling about self-referral communication, challenge to staff-patient relationship); 3) treatment decision making (decisional awareness and roles, cost-benefit trade-off and redicision). Conclusions: Our study identified that organizational and demographic factors, self-referral motives worked together at the self-referral decision-making and treatment decision-making when advanced CKD patients facing with healthcare facilities and treatment options. Those findings suggest stakeholders should accelerate the popularization of peritoneal dialysis technology and establish the CKD screening and management systems. For self-referral patients with advanced CKD, our results suggest specialized dialysis transition care to improve quality of communication and soothe patients’ negative emotion.

Download Full-text

Value-based evaluation of dialysis versus conservative care in older patients with advanced chronic kidney disease: a cohort study

BMC Nephrology ◽

10.1186/s12882-018-1004-4 ◽

2018 ◽

Vol 19 (1) ◽

Cited By ~ 14

Author(s):

Wouter R. Verberne ◽

Janneke Dijkers ◽

Johannes C. Kelder ◽

Anthonius B. M. Geers ◽

Wilbert T. Jellema ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Cohort Study ◽

Kidney Disease ◽

Older Patients ◽

Advanced Chronic Kidney Disease ◽

Conservative Care

Download Full-text

The transition clinic in chronic kidney disease care

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa022 ◽

2020 ◽

Vol 35 (Supplement_2) ◽

pp. ii4-ii10 ◽

Cited By ~ 1

Author(s):

Marie Evans ◽

Kai Lopau

Keyword(s):

Chronic Kidney Disease ◽

Decision Making ◽

Kidney Disease ◽

Patient Involvement ◽

Decision Making Process ◽

Shared Decision ◽

Advanced Chronic Kidney Disease ◽

Conservative Care ◽

Transition Clinic ◽

Chronic Kidney Disease Care

Abstract People with advanced chronic kidney disease and evidence of progression have a high risk of renal replacement therapy. Specialized transition clinics could offer a better option for preparing these patients for dialysis, transplantation or conservative care. This review focuses on the different aspects of such transition clinics. We discuss which patients should be referred to these units and when referral should take place. Patient involvement in the decision-making process is important and requires unbiased patient education. There are many themes, both patient-centred and within the healthcare structure, that will influence the process of shared decision-making and the modality choice. Aspects of placing an access for haemodialysis and peritoneal dialysis are reviewed. Finally, we discuss the importance of pre-emptive transplantation and a planned dialysis start, all with a focus on multidisciplinary collaboration at the transition clinic.

Download Full-text

Changing the choice for dialysis to conservative care or vice versa in older patients with advanced chronic kidney disease

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfab162 ◽

2021 ◽

Author(s):

Carlijn G N Voorend ◽

Wouter R Verberne ◽

Mathijs van Oevelen ◽

Yvette Meuleman ◽

Marjolijn van Buren ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Older Patients ◽

Advanced Chronic Kidney Disease ◽

Conservative Care

Download Full-text

Risk prediction for death and end-stage renal disease does not parallel the real-life trajectory of older patients with advanced chronic kidney disease – a Romanian center experience.

Archives of Medical Science ◽

10.5114/aoms/128741 ◽

2021 ◽

Author(s):

Nastasa Andra ◽

APETRII MUGUREL ◽

Onofriescu Mihai ◽

Nistor Ionut ◽

Voroneanu Luminita ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Mortality Risk ◽

Older Patients ◽

Real Life ◽

Low Risk ◽

Advanced Chronic Kidney Disease ◽

Risk Of Progression ◽

Life Trajectory ◽

End Stage

IntroductionIn 2016, the European Renal Best Practice (ERBP) group published a guideline on the management of older adults with advanced chronic kidney disease (CKD). Two risk scores were highlighted: Bansal score for mortality, and Kidney Failure Risk Equation (KFRE) for estimating progression to end-stage kidney disease (ESRD). Our group, as part of the ERBP team, aimed to apply these risk prediction tools in a cohort of older adults with eGFR <45 ml/min/1.73 m2.Material and methodsThis retrospective study included adults aged ≥65 years with CKD stage 3b-4, evaluated at a Romanian Outpatient Nephrology Department between October 2016 – October 2018. Bansal score was calculated for all subjects and then KFRE was used in the low mortality risk group. Outcomes were death or reaching ESRD. These outcomes were used to compare the difference between the estimated trajectory and real-life trajectory of patients. They were followed up until September 2019.ResultsFrom the total population (N=958 patients), more than half (N1=548, 57.2%) had a high mortality risk. In the remaining group with low mortality risk (N2=410, 42.8%), a significant percentage (75.4%) presented a low risk of progression to ESRD. Real-life events consisted of 164 deaths and 31 dialysis initiations. We found similar death rates in the two groups (high versus low risk of mortality). There was no difference in the rate of dialysis initiation between subjects with a high or low risk of progression to ESRD.ConclusionsRisk prognostication for death and ESRD did not parallel the real-life trajectory of our older patients with advanced CKD.

Download Full-text